Participatory Mapping in Bulambuli District Results in Doubling the Number of Underserved Communities Reached with Immunization and Other Health Services

The health system in Bulambuli District, located on the side of Mount Elgon in Uganda’s Eastern Region, is challenged by mountainous terrains, dispersed populations, and widely separated health facilities. In 2015, only 57% of infants had received a first dose of pentavalent vaccine, which protects against five diseases; vaccination coverage for measles stood at 48%. In mid-2016, USAID’s Maternal and Child Survival Program (MCSP) was asked to provide technical assistance to help Bulambuli district pinpoint and address the root causes of the problems leading to low vaccination coverage. By working strategically with both health officials and civil and administrative authorities, MCSP helped Bulambuli to more than double its reach for immunization and other basic health services from 340 villages in 2015 to 695 villages in 2017.

“MCSP, through mapping, helped us to realize that 27 parishes (7 sub-counties) could not easily access lifesaving immunization services. The statistics on the unreached population were startling and triggered district-led action that involved multiple stakeholders. With MCSP’s support, we are now reaching 695 villages with immunization services, up from the 340 originally reached, as a result of these new health facilities. We’ve also actively engaged our lower level leaders in committing tangible resources to these new health facilities to ensure their functionality.” Stephen Waniala, assistant district health officer - MNCH, Bulambuli

A key element of MCSP’s approach in Uganda is to apply tools from the field of quality improvement (QI) to the Uganda National Expanded Programme on Immunization (UNEPI) technical strategy called Reaching Every Community (REC). The MCSP approach, termed REC-QI, starts with a participatory approach to mapping of communities and their access to health facilities. MCSP convened health personnel, as well as local civil and administrative authorities, politicians, and community leaders to assign parishes – groups of 5-6 villages – to different health centers and outreach sites in the community. A close analysis of the map that they jointly constructed made them realize that 29% of Bulambuli’s population lived very far from any clinic or outreach site. Approximately 27 parishes and seven of the district’s 19 sub-counties, with a combined population of 53,084, had no health facilities at all. This meant that families with infants and small children had to travel at least eight kilometers to access basic, preventive care including immunization.

The mapping process prompted Bulambuli’s leadership to take action to improve the access of these underserved communities to health services. They tasked the administrations of six sub-counties to identify structures that could house new health facilities. The sub-county officials did so and worked with MCSP and other key officials to reallocate health workers to start providing health services at these new sites. But buildings and staff alone were not enough to provide health care. MCSP supported the sub-counties to formally apply to the Ministry of Health (MOH) to commission these new facilities so that they would receive full benefits, including supplies of vaccines, drugs, and equipment.

Since August 2017, these six health centers have operated in structures that include a locally-donated building, a former sub-county office, and a planned sub-county residence. Each is staffed with at least four trained health workers, assisted by village volunteers who offer immunization and other basic maternal, newborn, and child health (MNCH) services, both onsite and at nearby outreach sites. Establishment of these six health centers has greatly improved access to care: mothers with infants walk no more than two kilometers to health facilities or outreach sites and no longer incur out-of-pocket expenses of $5 for motorcycle taxi rides to benefit from the free preventive immunization services. Following this development, DTP3 coverage in Bulambuli rose to 76.5% while the vaccination drop-out rate fell to a level of only 1.4%.

From this experience, Bulambuli health officials learned the importance of using spatial data and engaging with local leaders to take action and commit resources to improve both the provision and use of such essential services as immunization. MCSP has worked in 11 districts across four regions of Uganda to strengthen the capacity of health personnel to manage and deliver immunization services and involve local civil, administrative, and political leaders for necessary support.

Background
Since 2014, the MCSP/Uganda, led by JSI, has supported the MOH to strengthen the RI system through the full implementation of UNEPI’s RED/REC approach with the following two key program objectives:

Improve district capacity to manage and coordinate the immunization program guided by UNEPI leadership.

Implemented in over 400 health facilities in 11 districts (Kanungu, Mitooma, Mbarara, Butebo, Pallisa, Bulambuli, Mayuge, Bushenyi, Ntungamo, Butaleja, Kibuku) in Uganda, the RED/REC approach used by MCSP seeks to ensure that all children and women of child-bearing age and special populations have access to quality and sustainable immunization services.

To accelerate the achievement of the second program aim, MCSP/Uganda has provided technical support at district and health facility level for the REC approach, leveraging on lessons from other implementation countries to include a REC-QI component. The REC-QI approach has several components, including the creation of facility-level quality work improvement teams that conduct monthly and quarterly meetings that are strengthened by district-led supportive supervision visits, which include review of RI data for action. From MCSP/Uganda’s experience, REC-QI has improved the capacity of health facility staff and community health workers to develop and use micro-plans to analyze, prioritize, and solve problems related to access and use of RI.